Mathematical modeling of fetal organ growth using the Rossavik growth model: IV. Lung

Growth of the fetal lung has been monitored by left lung area (LLA), right lung area (RLA), and total lung area (TLA) from 14 to 41 weeks menstrual age in 116 normal Japanese fetuses. Growth of the fetal heart and chest has also been monitored by heart area (HA) and chest area (CA), respectively. Growth curves for these parameters have been determined by using a Rossavik growth model [p = c(t)k+s(t)]. R2 values of 95.3%, 90.3%, 89.0%, 88.7%, and 92.1% were obtained for CA, HA, LLA, RLA, and TLA, respectively. Variability analysis indicated a progressive increase in variability with fetal age for these five parameters. Variability data were used with the growth curve models to determine standard curves for these parameters. These standard curves provide a superior means for evaluating the normal fetal lung growth in the fetus and for identifying pulmonary hypoplasia in utero.

[Quantitative analysis of myocardial tracer distribution in patients with ischemic heart disease: comparison of 201T1 and 123I-15-(p-iodophenyl)-3-methylpentadecanoic acid (BMIPP)]

Quantitative assessment of myocardial tracer uptake in stress-delayed thallium and resting BMIPP imagings were performed in 24 patients with coronary artery disease. Each distribution was displayed on the bull's eye polar map and % uptake of each distribution was calculated as a mean value in 9 myocardial segments on the polar map. Redistribution index (% delayed uptake minus % stress uptake on thallium images) and discordance index (% delayed thallium uptake minus % BMIPP uptake) were also calculated. Each parameter was compared to the visual uptake score and wall motion score on contract left ventriculography. Excellent correlations were obtained between % uptake and the uptake score in each tracer. The % thallium and BMIPP uptake also correlated with regional wall motion score. Furthermore, a significant correlation was observed between redistribution and discordance indexes in the mildly hypoperfused segments. These data indicate that the quantitative analysis of thallium and BMIPP distributions seems to be valuable to understand relationship between perfusion and regional wall motion. The discordant BMIPP uptake may represent asynergic but viable segments. However, several important factors, such as attenuation factor should be also taken into consideration for such quantitative analysis.

Longitudinal Doppler ultrasonographic assessment of alterations in regional vascular resistance of arteries in normal and growth-retarded fetuses

The objective of this longitudinal study was to evaluate alterations in regional vascular resistance of arteries with advancing gestation in normal and growth-retarded fetuses. Color Doppler flow imaging and pulsed Doppler ultrasonographic assessments were performed on 13 normal and 7 growth-retarded fetuses, ranging from 15 to 40 weeks menstrual age. The pulsatility index was calculated for middle cerebral artery, descending aorta, splenic artery, renal artery, femoral artery and umbilical artery, respectively. Optimal models for these pulsatility index values were determined by regression analysis. A normal range of the pulsatility index for each artery generated in the normal fetuses. In the middle cerebral artery, the models showed a parabolic pattern during pregnancy in the two groups and the predicted pulsatility index values in growth-retarded fetuses were always lower than those in the normal fetuses, especially late in pregnancy. In the renal artery, the predicted pulsatility index values in growth-retarded fetuses were higher than those in normal fetuses near term. In other arteries, the predicted pulsatility index values showed their own specific patterns and there were no significant differences in predicted pulsatility index values in the two groups. In conclusion, alterations in regional vascular resistance of arteries with advancing menstrual age occur evidenced in both normal and growth-retarded fetuses.

Chorangiosis and chorangioma in three cohorts of placentas from Nepal, Tibet, and Japan

It has been reported that both chorangiosis and chorangioma are increased in placentas at high altitudes. In this study, 1.14% of 2448 Japanese placentas obtained at 30-300 m had chorangiosis or chorangioma, compared with 3.24% of the Nepalese placentas (1300-3000 m) and 9.09% of the Tibetan samples (3800-4200 m). The incidence of both pathologies was significantly higher in the Himalayan groups than those of the Japanese group (P < 0.05). Obstetric complications of the 28 Japanese placentas with chorangiosis and chorangioma included Caesarean section 16 (57.1%), abruptio placentae 2 (7.14%), intrauterine growth retardation 3 (10.7%), intrauterine fetal death 4 (14.2%) and placenta praevia 4 (14.2%). Four infants (14.2%) had Apgar scores ranging from 0 to 3. Among 48 Himalayan placentas with chorangiosis and chorangioma, incidence of marked subchorionic fibrin was significantly higher (25%) than in the Japanese group (3.57%) (P < 0.05). The incidence of abnormal insertion of the cord was significantly higher (14.2%) in the Japanese group than in the Himalayan group (5%) (P < 0.05). There was no significant difference in the frequencies of intervillous thrombosis and infarction between the two groups. These findings suggest that the incidence of pathological change such as chorangiosis and chorangioma may be increased in placentas at Himalayan altitudes.

Sex-dependent and independent renal excretion of nilvadipine metabolites in rat: evidence for a sex-dependent active secretion in kidney

1. To clarify the mechanism of sex-dependent and independent kidney secretion of major nilvadipine metabolites (3, 7) in rat, renal clearance corrected for protein binding and glomerular filtration rate (GFR) was measured in both sexes. The effect of probenecid, an inhibitor of organic anion transport, on these measurements was also investigated. 2. Clear sex-dependent active secretion was observed in the renal excretion of 3 (3-carboxylic acid pyridine derivative). In the female rat, 3, clearance was approximately 32-fold greater than GFR and was markedly decreased by probenecid. Conversely, in the male rat, renal clearance of 3 was only a fraction of GFR and was unaffected by probenecid. 3. Sex-independent active secretion was observed in the renal excretion of 7 (5-carboxylic acid pyridine derivative). In both sexes of rat 7 clearance was about 22-fold greater than GFR and was markedly reduced by probenecid. 4. A clear presence of sex-dependent and independent active secretion mechanisms in the kidney has been demonstrated in rat. The female rat is able to eliminate 3 and 7 in urine by an active secretion mechanism that is inhibited by probenecid. In the male rat, a transport mechanism for 7 is present, but either lacks or is apparently inactive for 3.

Ophthalmic artery velocimetry in preeclampsia

Our objective was to compare ophthalmic artery pulsatility index values from normal pregnant women with those from preeclampsia patients. The ophthalmic artery of 20 normotensive pregnant women, 7 mildly preeclamptic and 2 severely preeclamptic patients was studied once with color Doppler flow imaging and pulsed Doppler ultrasonography after 32 weeks gestation. The peak systolic velocity [49.0 +/- 11.8 (SD) cm/s] in mild preeclampsia was significantly higher (p < 0.0001) than that (32.1 +/- 9.5 cm/s) in normotensive pregnant women, as were the end-diastolic velocity (14.1 +/- 7.7 cm/s vs. 3.7 +/- 1.4 cm/s, p < 0.0001) and time-averaged mean peak velocity (24.4 +/- 10.2 cm/s vs. 10.5 +/- 2.9 cm/s, p < 0.0001). The pulsatility index (1.58 +/- 0.47) in mild preeclampsia was significantly lower (p < 0.0001) than that (2.75 +/- 0.66) in normotensive pregnant women. In the 2 cases of severe preeclampsia, pulsatility index values (case 1: 1.86; case 2: 2.44) in the late stage of the disease process were significantly higher than those (case 1: 1.19; case 2: 1.20) in the early stage. We conclude that mild preeclampsia was associated with a significant decrease in ophthalmic artery vascular resistance, whereas ophthalmic artery vascular resistance in severe preeclampsia increased as the disease process advanced. However, in view of the small number of severe preeclamptic patients, these observations must be considered preliminary.

Effective treatment of drug-induced agranulocytosis using recombinant human granulocyte colony stimulating factor in pregnancy

Drug-induced immune system mediated agranulocytosis is a rare but potentially life-threatening condition. There have been only a few reports on the drug-induced agranulocytosis during pregnancy. We present a case of agranulocytosis after prolonged intravenous infusion of ritodrine hydrochloride and additional administration of indomethacin suppositories, effectively treated using recombinant human granulocyte colony stimulating factor without any infection in a mother with twin-to-twin transfusion syndrome. Recombinant human granulocyte colony stimulating factor may have a potential use for drug-induced agranulocytosis during pregnancy.

[Surgical repair of valvular diseases in patients over 75 years of age]

From January 1985 through August 1993, 41 patients older than 70 years underwent valvular surgery. In them, 10 patients were older than 75 years old. We evaluated those operative results. First, we classified them into 3 groups; Group A: over 75 y.o. (10 cases), Group B: 70-74 y.o. (31 cases) and Group C: 60-69 y.o. (39 cases, from January 1992 through August 1993). Surgical deaths were 1 case in Group A, and 1 in Group B. Distant deaths were 1 case in Group B, and 2 in Group C. Preoperative cardiac catheterization data showed the progression of cardiac failure in proportion to aging. But postoperative data showed no difference among 3 groups, and the condition was reversible. NYHA classification and cardiothoracic ratio (CTR) showed the same results. In summary, in valvular diseases in patients over 75 years of age, the progression of the condition was recognized but it was reversible. So we conclude that the surgical repair of no influence of age is necessary.

Osteotropic drug delivery system (ODDS) based on bisphosphonic prodrug. I: synthesis and in vivo characterization of osteotropic carboxyfluorescein

An osteotropic drug delivery system (ODDS) based on a bisphosphonic prodrug was designed as a novel method for site-specific and controlled delivery of drugs to the bone. Due to the chemical adsorption of bisphosphonic promoiety to the mineral component, hydroxyapatite, a bisphosphonic prodrug is predominantly taken up into the bone. To verify the concept, bisphosphonic promoiety was chemically introduced into 6-carboxyfluorescein (CF) as a model compound and the disposition after intravenous injection was studied in rats. The bisphosphonic prodrug of CF, disodium (fluorescein-6-carbonyloxy) acetoaminomethylene bisphosphonate (CF-BP) was highly taken up to the skeleton (62.1% of dose) and the remainder was excreted into the urine (35.9% of dose). Subsequently, regeneration of CF by hydrolysis of CF-BP in the bone was observed. The microscopic observation showed that CF-BP was buried into the bone with a calcification of the bone. According to the remodeling of the bone, bisphosphonic prodrug buried was supposed to be released in the vicinity of the osteoclast or resorption surface of the bone. Thus, it is suggested that ODDS has a potential to achieve osteoclast-specific or resorption surface-specific targeting of the drugs.

Further metabolism of FK506 (tacrolimus). Identification and biological activities of the metabolites oxidized at multiple sites of FK506

To characterize the metabolic pathway of FK506 (tacrolimus), FK506 or its 31-O-desmethyl metabolite was incubated with liver microsomes prepared from dexamethasone-treated rats in the presence of a NADPH-generating system under aerobic conditions. Besides the four oxidized metabolites already reported, four new metabolites were isolated and identified by HPLC, mass spectrometry, and NMR spectroscopy, and their biological activities were examined. The di-demethylated metabolites at the 15- and 31-, 13- and 31-, and 13- and 15-methoxy groups of FK506, were designated respectively as M-V, M-VI, and M-VII. The fourth, M-VIII, was the metabolite produced after O-demethylation at the 31-methoxy group and formation of a fused 10-membered ring structure through the 19- to 22-carbon of the macrolide ring after oxidation of the 19-methyl group, and of the 36- and 37-vinyl group of FK506. The immunosuppressive activity of the isolated metabolites was estimated in a mouse mixed lymphocyte reaction system and the IC50 values for M-V, M-VI, M-VII, M-VIII, and FK506 were > 1000, 8.78, > 1000, 15.27, and 0.11 ng/ml, respectively. Reactivity of the metabolites with mouse anti-FK506 monoclonal antibody was studied and immunocrossreactivity of M-V was 92.3% of FK506, but no reactivity was observed for M-VI, M-VII, and M-VIII. FK506 thus was metabolized at multiple sites by rat hepatic microsomes and the metabolites formed (M-V) - (M-VIII) exhibited weak or negligible immunosuppressive activity.

[Clinicopathological report of cisplatin encephalopathy]

A 61-year-old woman was treated with cisplatin and etoposide for ovarian carcinoma. After the second course of chemotherapy she developed acute encephalopathy which manifested itself as headache, fever, a partial seizure, confusion, and mild right hemiparesis, although no evidence of a central nervous system infection was found. Ten days after the onset of neurological symptoms, she experienced a sudden loss of vision in both eyes. Neurological findings were compatible with cortical blindness. Neurological symptoms subsided and visual acuity completely returned over the next months. The total cumulative dose of cisplatin was 325 mg/m2. She died of aspiration pneumonia on the 43rd day. Postmortem examination revealed severe nerve cell loss, gliosis and spongy changes in the bilateral occipital cortex including visual field, and slight to moderate demyelination in the subcortical white matter of the occipital cortex, Goll's tract, and dorsal root ganglia. As far as we know this encephalopathy is the second report in which the neuropathological changes associated with cisplatin therapy have been demonstrated by autopsy findings. The first was a case report of leukoencephalopathy, which differed significantly from our case in the primary lesions of the brain. We measured the platinum level in several parts of the cerebrum and cerebellum, optic nerve, spinal cord, and cauda equina by using an atomic absorption spectrophotometric technique. Platinum was detected in the bilateral occipital cortex, spinal cord, and cauda equina. These results were consistent with the distribution of pathological lesions. The mechanism of cisplatin-induced focal encephalopathy remains speculative.(ABSTRACT TRUNCATED AT 250 WORDS)

Hypoplastic left heart syndrome: color Doppler sonographic and magnetic resonance imaging features in utero

A 26-year-old Japanese woman, gravida 2, para 1, was referred to our ultrasonography clinic at 27 weeks' gestation, because of a suspected fetal heart anomaly. The hemodynamic examination, specific for hypoplastic left heart syndrome and obtained with color Doppler sonography, gave a clue to an accurate diagnosis of this entity. Moreover, the use of magnetic resonance imaging provided information complementary to the sonographic findings. The sophisticated type of fetal cardiac examination with color Doppler sonography and magnetic resonance imaging was very effective to interpret hypoplastic left heart syndrome with total anomalous pulmonary venous return. An accurate prenatal diagnosis of congenital heart anomalies is useful for obstetrical management.

Effect of dehydroepiandrosterone sulfate on uterine artery flow velocity waveforms in term pregnancy

OBJECTIVE

To investigate the interrelation between estrogen synthesis by the fetoplacental unit and uteroplacental hemodynamics in term pregnancy.

METHODS

Transvaginal color Doppler flow imaging and pulsed Doppler ultrasonographic assessments were made on ten normal full-term pregnant women before and 3, 5, 10, 30, and 60 minutes after the administration of a 200-mg intravenous dose of dehydroepiandrosterone sulfate (DHAS) in 20 mL of 5% dextrose. Ten normal full-term pregnant women received 20 mL of 5% dextrose as controls. The pulsatility index (PI) values for the uterine artery, heart rate, and mean arterial pressure were recorded. Plasma estradiol (E2) was measured before and 10 minutes after the infusion.

RESULTS

In the DHAS group, uterine artery PI decreased from baseline by 26% (P < .05) after 5 minutes, and the mean reduction was 36% (P < .05) after 10 minutes and 15% (P < .05) after 30 minutes. The PI returned to the baseline value 60 minutes later. In the control group, there was no change in uterine artery PI. No change was found in heart rate or mean arterial blood pressure in the control or DHAS groups. The mean plasma E2 increased from 22.3 +/- 6.6 to 56.2 +/- 24.1 ng/mL (P < .05) 10 minutes after the infusion in DHAS subjects, whereas there was no significant change in plasma E2 in the controls.

CONCLUSION

Dehydroepiandrosterone sulfate induces a significant decrease in the uterine artery PI, which suggests a possible decrease in uterine vascular impedance in term pregnancy.

Modulation of adrenergic receptors during regression of cardiac hypertrophy

OBJECTIVE

To determine whether alpha 1- or beta-adrenergic receptors are altered during regression of cardiac hypertrophy produced by antihypertensive agents.

DESIGN AND METHODS

Cardiac hypertrophy was induced in rats by aortic banding. After 6 weeks banding the rats were treated with an angiotensin converting enzyme (ACE) inhibitor (enalapril), an alpha 1-adrenergic antagonist (bunazosin) or a beta-adrenergic antagonist (propranolol) for 6 weeks to induce regression. The numbers of alpha 1- and beta-adrenergic receptors, haemodynamics, tissue noradrenaline content and tissue ACE activity were measured.

RESULTS

Regression of cardiac hypertrophy occurred after treatment of aortic banded rats with a high dose of enalapril, bunazosin or propranolol, and was accompanied by a reduction in systolic blood pressure. The number of alpha 1- or beta-adrenergic receptors was unchanged by propranolol treatment, but the number of alpha 1-adrenergic receptors was increased in the hearts of rats treated with bunazosin. A low dose of enalapril (3 mg/kg body weight) caused regression of hypertrophy without a concomitant reduction in blood pressure, and decreased the number of alpha 1-adrenergic receptors. The dissociation constants for alpha 1- and beta-adrenergic receptors were not different among the experimental groups, and the positive derivatives of left ventricular pressure was unaltered in rats treated with a low dose of enalapril but was reduced by the other drugs.

CONCLUSION

Of the three drugs tested, only the low dose of enalapril affected adrenergic receptors during regression of cardiac hypertrophy, causing a decrease in alpha 1-adrenergic receptor number without a reduction in blood pressure. This effect may be explained by non-haemodynamic actions of the ACE inhibitor enalapril, probably by modulation of peripheral sympathetic activity.

[Immunocytochemistry in the diagnosis of acute myeloid leukemia (M0)]

We examined leukemic blasts from 5 cases of AML-M0 diagnosed according to The French-American-British (FAB) classification for expression of immunological markers as well as myeloperoxidase (MPO) using flow cytometry (FCM) and immunocytochemistry (ICC). In one patient, the myeloid antigens, CD13 and CD33, were negative on FCM, but apparently positive in the cytoplasm by ICC, leading to a diagnosis of AML-M0. We examined MPO with anti-MPO monoclonal antibody in four patients by ICC, and could detect 3% or more MPO positive rates in all cases. These findings indicate that immunological studies for MPO and myeloid markers using ICC are very useful for the diagnosis of AML-M0. Two of 5 patients achieved CR, but they relapsed soon or after one year, respectively. The treatment outcomes suggest that the AML-M0 is an AML subtype with poor prognosis.

Intramyocardial angiomyolipoma

We report a case of cardiac angiomyolipoma in a 48-year-old woman who went to the hospital because of shortness of breath. Cardiac ultrasonography showed a right atrial mass, which was surgically removed. Pathologic examination revealed a 6-cm-diameter, dome-shaped mass composed of a mixture of blood vessels, smooth muscle, and fat. Because of its distinctive morphology and location, we diagnosed it as an intramyocardial angiomyolipoma. There was no evidence of tuberous sclerosis. Since excision of the mass, the patient has remained well without recurrence for 20 months. Angiomyolipomas usually develop in the kidney; extrarenal occurrence is rare. To date, no case of a cardiac angiomyolipoma has been reported in the English literature. The histogenesis of angiomyolipoma is uncertain, but it is most likely hamartomatous in nature.

Interaction of renal excretion between nilvadipine metabolites, M3 and M7 in rats: characterization of sex-dependent and sex-independent active secretion in the kidney

The interaction of renal clearance between nilvadipine metabolites, M3 and M7, in male and female rats including protein binding and renal excretion was investigated to clarify the mechanisms involved. In male rats, active renal secretion of M7 (the 5-carboxylic acid pyridine derivative) was reduced in inverse proportion to the molar ratio of the plasma concentration M3/M7 after an i.v. dose of M3 (the 3-carboxylic acid pyridine derivative), and the dosed M3 was excreted only by glomerular filtration. In female rats, the active renal secretion of M7 was unaffected after an i.v. dose of M3, and the dosed M3 was excreted by active secretion. These results indicate an interference of the active secretion of M7 in male rats by M3 on competitive interaction at the renal tubular secretion, even though M3 was excreted only via a filtration process. Female rats may have two distinct and separate active renal secretion mechanisms for M7 and M3, even though these carboxylic acid compounds were eliminated by active transport in the kidney.

Long-term effects of pravastatin on serum lipid levels in elderly patients with hypercholesterolemia

The purpose of this study was to evaluate the long-term efficacy and tolerability of pravastatin, a 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor, in elderly patients with hypercholesterolemia. Pravastatin was administered for 12 months at a mean final dose of 9.9 mg/d to 208 elderly patients (mean [+/- SD] age, 70 +/- 7 years) with levels of total serum cholesterol greater than 5.69 mmol/L. The mean total cholesterol level was significantly decreased from 6.85 +/- 0.80 mmol/L to 5.59 +/- 0.70 mmol/L after 3 months, and this decrease was maintained thereafter. A similar change was observed in the mean serum level of low-density lipoprotein cholesterol. Although the mean serum level of high-density lipoprotein cholesterol in all the patients did not change significantly, the level in 34 patients with a value lower than 1.03 mmol/L was significantly increased after 3 months and thereafter. The serum level of triglycerides in all patients was significantly decreased after 3 months and thereafter and the decrease was more marked in 101 patients with levels greater than 1.73 mmol/L. In 168 elderly patients receiving 10 mg/d of pravastatin, there were significant negative correlations between the percent decrease in total cholesterol and both baseline total serum cholesterol level (r = -.354, P < 0.001) and age (r = -.208, P = 0.007). No serious side effects were observed. These results indicate that long-term administration of pravastatin is beneficial in the treatment of hypercholesterolemia in elderly patients.

Fetal liver length measurement does not provide a superior means for prediction of a small for gestational age fetus

To assess the growth of the fetal liver in normal pregnancies and evaluate the ability of fetal liver length measurement for prediction of small for gestational age fetuses, ultrasonographic examinations were performed on 162 normal fetuses, ranging from 15 to 40 weeks menstrual age. The optimal mathematical function and normal range of liver length were generated. The liver length was obtained in 21 small for gestational age fetuses between 34 and 40 weeks, and the ability to use fetal liver length measurement for prediction of small for gestational age fetuses was investigated. A curvilinear relationship was found between the menstrual age and liver length (R2 = 91.9%), and a normal range of liver length measurement for estimating the growth of the fetal liver during normal pregnancy was generated. The liver length was normal in 19 of 21 small for gestational age fetuses (90.5%). The fetal liver length measurement does not provide a superior means for identifying the small for gestational age fetus.

Mathematical modeling of fetal organ growth using the Rossavik growth model: III. Cardiac ventricle

Growth of the fetal cardiac ventricle has been monitored by total cardiac diameter (TCD), left ventricular systolic (LVSD) and diastolic diameter (LVDD), right ventricular systolic (RVSD) and diastolic diameter (RVDD), left ventricular width (LVW), interventricular septal width (IVSW), and right ventricular width (RVW) from 19 to 39 weeks, menstrual age, in 114 normal Japanese fetuses. Growth curves for these parameters have been determined using a Rossavik growth model [P = c(t)k+s(t)]. R2 values of 89.7, 58.0, 65.3, 77.9, 80.3, 31.1, 30.1, and 26.9 were obtained for TCD, LVSD, LVDD, RVSD, RVDD, LVW, IVSW, and RVW, respectively. Variability analysis indicated a progressive increase in variability with fetal age for these eight parameters. Variability data were used with the growth curve models to determine standard curves for these parameters. These standard curves provide a superior means for evaluating the normal fetal cardiac growth in the fetus and for identifying congenital heart anomalies in utero.

An accurate antenatal diagnosis of vasa previa with transvaginal color Doppler ultrasonography

We describe a case of vasa previa diagnosed antenatally with transvaginal color Doppler ultrasonography. The diagnosis was confirmed at cesarean delivery. The benefits and advantages of the use of transvaginal color Doppler ultrasonography to diagnose vasa previa in utero are discussed.